Section 1357.514 Of Article 3.16. Nongrandfathered Small Employer Plans From California Health And Safety Code >> Division 2. >> Chapter 2.2. >> Article 3.16.
1357.514
. In connection with the offering for sale of a small
employer health care service plan contract subject to this article,
each plan shall make a reasonable disclosure, as part of its
solicitation and sales materials, of the following:
(a) The provisions concerning the plan's right to change premium
rates and the factors other than provision of services experience
that affect changes in premium rates. The plan shall disclose that
claims experience cannot be used.
(b) Provisions relating to the guaranteed issue and renewal of
contracts.
(c) A statement that no preexisting condition provisions shall be
allowed.
(d) Provisions relating to the small employer's right to apply for
any small employer health care service plan contract written,
issued, or administered by the plan at the time of application for a
new health care service plan contract, or at the time of renewal of a
health care service plan contract, consistent with the requirements
of PPACA.
(e) The availability, upon request, of a listing of all the plan's
contracts and benefit plan designs offered, both inside and outside
the Exchange, to small employers, including the rates for each
contract.
(f) At the time it offers a contract to a small employer, each
plan shall provide the small employer with a statement of all of its
small employer health care service plan contracts, including the
rates for each plan contract, in the service area in which the
employer's employees and eligible dependents who are to be covered by
the plan contract work or reside. For purposes of this subdivision,
plans that are affiliated plans or that are eligible to file a
consolidated income tax return shall be treated as one health plan.
(g) Each plan shall do all of the following:
(1) Prepare a brochure that summarizes all of its plan contracts
offered to small employers and to make this summary available to any
small employer and to solicitors upon request. The summary shall
include for each contract information on benefits provided, a generic
description of the manner in which services are provided, such as
how access to providers is limited, benefit limitations, required
copayments and deductibles, and a telephone number that can be called
for more detailed benefit information. Plans are required to keep
the information contained in the brochure accurate and up to date
and, upon updating the brochure, send copies to solicitors and
solicitor firms with whom the plan contracts to solicit enrollments
or subscriptions.
(2) For each contract, prepare a more detailed evidence of
coverage and make it available to small employers, solicitors, and
solicitor firms upon request. The evidence of coverage shall contain
all information that a prudent buyer would need to be aware of in
making contract selections.
(3) Provide copies of the current summary brochure to all
solicitors and solicitor firms contracting with the plan to solicit
enrollments or subscriptions from small employers.
For purposes of this subdivision, plans that are affiliated plans
or that are eligible to file a consolidated income tax return shall
be treated as one health plan.
(h) Every solicitor or solicitor firm contracting with one or more
plans to solicit enrollments or subscriptions from small employers
shall do all of the following:
(1) When providing information on contracts to a small employer
but making no specific recommendations on particular plan contracts:
(A) Advise the small employer of the plan's obligation to sell to
any small employer any small employer health care service plan
contract, consistent with PPACA, and provide the small employer, upon
request, with the actual rates that would be charged to that
employer for a given contract.
(B) Notify the small employer that the solicitor or solicitor firm
will procure rate and benefit information for the small employer on
any plan contract offered by a plan whose contract the solicitor
sells.
(C) Notify the small employer that upon request the solicitor or
solicitor firm will provide the small employer with the summary
brochure required under paragraph (1) of subdivision (g) for any plan
contract offered by a plan with which the solicitor or solicitor
firm has contracted to solicit enrollments or subscriptions.
(D) Notify the small employer of the availability of coverage and
the availability of tax credits for certain employers consistent with
PPACA and state law, including any rules, regulations, or guidance
issued in connection therewith.
(2) When recommending a particular benefit plan design or designs,
advise the small employer that, upon request, the agent will provide
the small employer with the brochure required by paragraph (1) of
subdivision (g) containing the benefit plan design or designs being
recommended by the agent or broker.
(3) Prior to filing an application for a small employer for a
particular contract:
(A) For each of the plan contracts offered by the plan whose
contract the solicitor or solicitor firm is offering, provide the
small employer with the benefit summary required in paragraph (1) of
subdivision (g) and the premium for that particular employer.
(B) Notify the small employer that, upon request, the solicitor or
solicitor firm will provide the small employer with an evidence of
coverage brochure for each contract the plan offers.
(C) Obtain a signed statement from the small employer
acknowledging that the small employer has received the disclosures
required by this section.